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The Queen Elizabeth Hospital
Single Incision LAPAROSCOPIC SURGERY
(SILS) COLORECTAL Resection
Nick Rieger
Assoc Professor
University of Adelaide
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The Queen Elizabeth Hospital
SILS• Urology
• Renal transplant
• Cholecystectomy
• Gastric band surgery
• Colectomy
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The Queen Elizabeth Hospital
SILS
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The Queen Elizabeth Hospital
SILS Colectomy and literature• 2 recorded cases
• Remzi FH, Kirat HT, Kaouk JH, Geisler DP. Single-port laparoscopy in colorectal surgery. Colorectal Dis. 2008 Oct;10(8):823-6. Epub 2008 Aug 5.
• Bucher P, Pugin F, Morel P. Single port access laparoscopic right hemicolectomy. Int J Colorectal Dis. 2008 Oct;23(10):1013-6. Epub 2008 Jul
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The Queen Elizabeth Hospital
Colectomy ?? HOW• Open Incision
• Laparoscopic assisted
• Laparoscopic Hand assisted
• Total laparoscopic
• SILS
• Endoscopic submucosal excision
• NOTES ??
• Robotic ??
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The Queen Elizabeth Hospital
SILS Colectomy
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The Queen Elizabeth Hospital
SILS Colectomy
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The Queen Elizabeth Hospital
Case Experience: Dr Rieger• 7 cases from 28/11/2008 until 10/3/2009
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The Queen Elizabeth Hospital
Patient Age BMI Tumour Path Nodes
1 83 23 Caecum T1N0 0/10
2 63 21.5 Splenic T3N0 0/12
3 76 23 Caecum Benign (5 cm)
26
4 69 24 Ileal
Liver 2nd
carcinoid 3/16
5 74 22 Caecum T2N0 0/10
6 73 25 Caecum T2N1 1/7
7 60 28 Ascend Benign (2 cm)
21
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The Queen Elizabeth Hospital
Patient Op Time
Stay Complication
1 100 4 Nil
2 75 4 Nil
3 90 4 Nil
4 75 6 Nil
5 115 11 bacteraemia
6 80 4 Nil
7 88 5 Nil
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The Queen Elizabeth Hospital
SILS. Why Bother?• Cosmesis
• Smaller single incision (2.5-4.5 cm)
• Length of stay ???
• Less risk hernia
• Less risk tumour implantation
• Stepping stone to NOTES
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The Queen Elizabeth Hospital
SILS: Indications• Benign neoplasm of colon
• Carcinoma of colon (small)
• Tumour size less than incision (2.5cm)
• Thin patient
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The Queen Elizabeth Hospital
SILS: Ideal Indications• Right sided pathology proximal to the hepatic
flexure
• Left sided pathology distal to the mid-transverse colon and proximal to the sigmoid colon.
• Small bowel pathology
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The Queen Elizabeth Hospital
SILS: Disadvantages• 2 operating ports
• Instrument clash
• Loss of tissue triangulation
• Learning curve of flexible instrumentation
• No 90 degree staplers for transection rectum
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The Queen Elizabeth Hospital
Ink Impalpable Lesions
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The Queen Elizabeth Hospital
Operative Considerations• Table
• Anaesthesia
• Trocars
• Instruments
• Anastomosis
• Oncologic principles
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The Queen Elizabeth Hospital
SILS : Trocars1 X 5-12mm Bluntport Plus (Covidien,)
2 X 5mm Dexide Threaded Trocar (Covidien)
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The Queen Elizabeth Hospital
SILS : Instruments• 30 degree 10 mm camera
• Roticulator Endo Mini-Shears 5mm (Covidien)
• Straight non-disposable atraumatic bowel grasper.
• Alexis® Wound retractor; small. (Applied Medical)
• Ligasure Advance (Covidien)
• Vicryl endoloop (Ethicon)
• DST GIA 80 – 3.8mm stapler and cartridge reload. (Covidien)
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The Queen Elizabeth Hospital
SILS: Anastomosis
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The Queen Elizabeth Hospital
SILS: Oncologic principles
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The Queen Elizabeth Hospital
Port site hernia
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The Queen Elizabeth Hospital
SILS: Post Operative Care• DVT prophylaxis
• Opiate Analgesia (PCA or S/C)
• Oral analgesia
• Mobilise Day 1
• Urine catheter out early (24 hours)
• Early introduction of fluids (first 24 hours) and diet (second 24 hours if fluids tolerated)
• IVT out once fluids tolerated
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The Queen Elizabeth Hospital
Conclusions• SILS colon resection is feasible.
• Can be achieved with the same or reduced cost as standard laparoscopic resection.
• Very specific indications